ML20045E440
| ML20045E440 | |
| Person / Time | |
|---|---|
| Site: | Westinghouse |
| Issue date: | 06/04/1993 |
| From: | Bassett C, Kasnicki D, Mcalpine E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20045E427 | List: |
| References | |
| 70-1151-93-03, 70-1151-93-3, NUDOCS 9307020115 | |
| Download: ML20045E440 (23) | |
Text
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UNITED STATES
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NUCLEAR REGULATORY COMMISSION 4
REGION 11
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't 9
101 MARIETTA STREET, N.W., SUITE 2900 j
ATLANTA, GEORGIA 30323-0199 -
%,,$./
gl041993 Report'No.:
70-1151/93-03 Licensee:
Westinghouse Electric Corporation Commercial Nuclear Fuel Division Columbia, SC 29250 Docket No.:
70-1151 License No.:
SNM-1107 Facility Name:
Columbia Nuclear Fuel Plant Inspection Conducted:
ril 19-23 and May 3-7, 1993 t
Inspector:
ot vw b/
3 C.
Hr--Intst
/
Date S'gned Inspector:
mM u Ete<_1.
b4D D. A. Kas31.eK1 O
Ddte bi'gned Approved by:
O wo b
E.
J. McAlpine, Chief 1
Date Signed Radiation Safety Projects Section Nuclear Materials Safety and Safeguards Division of Radiation Safety and Safeguards
SUMMARY
scope:
This routine, unannounced inspection involved a review of the nuclear criticality safety program with special emphasis on the program developed to identify, eliminate, and/or control moveable, non-favorable geometry (MNFG) containers in the facility; and the control of transfers from favorable to non-favorable geometry containers under moderation control.
The inspection also involved followup and review of thel actions taken in response to various-incidents that-have occurred at the facility, previously identified inspection items, and Information Notices.
Results:
The Nuclear Safety Assessments have been completed for those MNFG
.l containers that the licensee plans to continue using.
The affected procedures have been or are being revised to reflect the 9307020115 930604 PDR ADOCK 07001151 C
1 2
controls established for their use.
A new procedure has been completed which details the general requirements for using MNFG containers and includes a list of those MNFG containers authorized to be used in specific locations of tha plant.
Various Inspector Followup Items (IFIs) reviewed during the inspection were closed.
These included selected IFIs that were
{
documented in NRC Inspection Report Nos. 70-1151/91-02, 70-1151/92-02, and 70-1151/92-09 (Paragraph 4).
One'new issue was identified relative to the licensee's efforts to resolve problems with floor storage and storage of empty favorable geometry containers.
This issue will be tracked as an IFI (Paragraph 2.c).
Within the scope of the inspection, various issues were identified that appeared to be violations of license condition..
These issues included:
Three examples of failure to follow procedures for working in a ventilation hood, for handling combustible scrap and for posting a storage rack (Paragraphs 2.a, 2.b, and 2.c),
Removal of safety equipment required by license conditions (Paragraph 2.d),
i Failure to implement nuclear criticality safety controls which were sufficient to comply with the Double Contingency Principle which resulted in two_ examples of losing adequate i
barriers as a-result of failure to comply with the license application and with procedural requirements regarding performing moisture analyses prior to transferring powder from favorable to non-favorable geometry containers.
The remaining " barriers," which were not adequate to meet the Double Contingency, were the recognition by an individual l
that the material to be placed in the blender was-of the wrong consistency and/or moisture' content and the fact that the process inherently produced powder of low-moisture content.
(Paragraphs 2.2.2, 2.e.3 and 2.e.5),
Failure to follow procedures relative to blending of a sample prior to moisture analysis (Paragraph 2.e.4),_and A non-cited violation for failure of QC inspectors to follow procedures regarding storage of pellets, using an RWP, and dispositioning reject pellets (Paragraph 4.1).
9 l
i j
REPORT DETAILS 1.
versons Contacted Licensee Employees I
- J.
Berry Manager, Pellet and Rod Manufacturing
/J. Bush, Manager, Product Assurance j
/*B. Ergle, Manager, Manufacturing Automation Project-Team i
- J. Fici, Plant Manager
- D. Goldbach, Manager, Chemical Process Engineering
- W.
Goodwin, Manager, Regulatory Affairs J
- E. Keelen, Manager, Fuel Manufacturing
- N. Kent, Nuclear Criticality Safety Engineer
/G. LaBruyere, Manager,' Conversion Services
/*G. Lowder, Manager, Maintenance
- S. Mcdonald, Manager, Technical Services and Acting: Plant-Manager (during the first week of the inspection)
R. Montgomery, Nuclear Criticality Safety Engineer
- R.
Pollard, Manager, Production Assurance Engineering
- D. Precht, Manager, Materials Planning and Services
/*C. Sanders, Manager, Nuclear Materials Management & Product Records
- L.
Turner, Supervisor, Uranium Recovery & Recycle Services
/W. Ward, Manager, Uranium Recovery' Recycle Services
- D.
Williams, Nuclear Criticality Safety Engineer j
- R. Williams, Technical Coordinator, Regulatory Affairs other licensee employees contacted during the inspection included engineers, technicians,- operators, security personnel and office personnel.
- Attended the exit interview on April 23, 1993
- Attended the exit interview on May 7, 1993 2.
Operations Review (88015, 88020)
Condition 9 of Special Nuclear Material License Number 1107
.(SNM-1107) requires that licensed material be-used in accordance with statements, representations, and conditions contained in Chapters 2, 3,
and 4 of the application dated March 26, 1984, and supplements thereto.
Chapter-2, Section-2.6 of License SNM-1107 states that special nuclear material processing shall be conducted in accordance with approved written procedures or instructions.
During tours of the facility the inspector noted three problems which appeared to be caused by personnel failing to follow procedures.
These are outlined below.
1 t
i 2
a.
Ventilation Hood Operations
-l Regulatory Affairs Procedure, RA-302, " Criticality Signs," Revision (Rev.)
6, dated April 1, 1993, states in Section 6 that area supervision is responsible to ensure compliance with criticality control parameters and instructions on criticality signs.
The Criticality Sign posted on the ventilation hood l
(the hood near the Solvent Extraction Control Room and l
adjacent to the dissolvers) specified a limit of three polypaks inside the hood and that twelve inches be maintained between the polypaks.
l l
During a tour of the solvent extraction (SOLX) area on the evening of April 21, 1993, the inspector noted that there were four polypaks located inside the ventilation hood located near the SOLX Control Room.
It was also noted that three of the polypaks appeared to have some material inside while the fourth polypak appeared to be empty except for a scoop.
One of the full polypaks was located on a scale inside the hood.
Two of the full i
polypaks and the empty one were located within six to eight inches of each other, with the empty polypak i
being approximately in the middle of the group.
No one H
was working in the hood at the time and no one was in the immediate area.
Approximately ten minutes later, an operator approached the hood and removed the polypak that had been located on the scale.
l Failure to follow posted instructions by locating four l
polypaks inside the ventilation hood and spacing them from six to eight_ inches apart was identified as a violation of License Condition 9 (VIO 70-1151/93 01).
l b.
Radioactive Scrap Generation and Control Chemical Operating Procedure, COP-841000, " Low-Level Radioactive Scrap Handling," Rev.
5, dated February 26, 1993, states in Section 7.1.3 that containers for combustible scrap must meet Factory. Mutual requirements (e.g., metal container with fire safe lid).
Revision 6 of COP-841000, dated April-22,'1993,- states in Section 7.1.9(B) that, for combustible trash, there must be at I
least twelve inches of space maintained between all trash cans and/or trash bags.
During tours of the facility on the morning of April 21, 1993, the inspector noted that repair work was apparently in progress on a pellet press located in the general area of Pellet Line No. 5 and across from I
L
3 the Stratification Blender.
Located in the area around the repair work were two red 5-gallon scrap cans.
Also, laying on the floor in the general area were three plastic bags containing what appeared to 5 dirty l
rags.
One bag was laying beside one of the red 5-gallon scrap cans, one bag was laying approximately three feet from the other red 5-gallon scrap can, and the third bag was near the pellet press.
At approximately 6:15 p.m. that evening, two of the plastic bags containing. dirty rags and an unbagged dirty rag were noted laying on the floor next to a red 5-gallon scrap can and a wet, dirty mop head was laying on the floor approximately six feet away.
These items were still located-in the same positions at approximately 7:15 p.m.
At approximately 8:15 a.m. On April 22, 1993, the two bags containing dirty rags and the unbagged dirty rag were noted.to still be laying on the floor next to the red 5-gallon scrap can.
There had apparently been some type of activity in the area on the evening of April 21 and on the morning of April 22.
However, the plastic bags and the rag had not been placed in a scrap can.
Using plastic bags instead of metal 5-gallon cans as scrap containers and not maintaining the required spacing between trash cans and bags was identified as another example of failure to follow procedure and a violation of License Condition 9 (VIO 70-1151/93 01).
c.
Postings Regulatory Affairs Procedure, RA-302, " Criticality Signs," Rev.
6, dated April 1, 1993, states in Section 6 that area supervision is responsible to ensure compliance with criticality control parameters and instructions on criticality signs.
The Criticality Sign posted on one storage rack in the SOLX area stipulated that the material authorized to be stored in the rack was incinerator ash in ammo. cans or polypaks.
During tours of the facility the inspector observed the postings on storage racks, storage carts, and ventilation-hoods.
In the general SOLX area, one storage rack and various storage carts were posted for the storage of various types of material.
The posting on the storage rack authorized incinerator ash to be stored there in ammo cans or polypaks.
The storage carts were posted such that the material authorized to
4 be stored there included dry UO2 pellets, U0, Ufos 2
powder, or scrap.
However, the rack and carts basically had the same material stored on them which included polypaks of dried residue for burial, press cake, ash, sludge, and torit (bag filter) fines.
In discussing this apparent problem with licensee representatives, they indicated that the postings on the storage rack and carts were not sufficiently descriptive of what is allowed to be stored there.
The licensee also stated that the criticality sign on the storage rack was an old posting and was no longer completely applicable.
Through various analyses that had been performed by the licensee, only larger sized polypaks containing powder with greater than one weight percent moisture would be prohibited from being stored on either the rack or the carts.
During this discussion, the licensee also indicated that the postings throughout the facility were being reviewed and revised as needed.
It was noted that a team had been established to address the issue of postings, as well as floor storage and storage of empty favorable geometry containers.
Failure to follow the instructions on the criticality sign for the storage rack was identified as another example of a violation of Condition 9 (VIO 70-1151/
93-03-01).
The licensee was also notified that their actions to resolve the issue of floor storage and empty container storage would be tracked and followed by the NRC as an Inspector Followup Item (IFI 70-1151/93-03-02).
d.
IDR Check Hopper Moisture Analyzers Section 2.2.14.1(14) of the license application states that check hopper moisture analyzers shall be provided as part of the IDR conversion system.
Licensee representatives informed the inspector that on February 16, 1993, while performing a self-initiated "zero" base verification" project to verify system configuration against the requirements of their license application, they identified that the check' hopper moisture analyzers had been replaced with sampling and laboratory analysis.
The nuclear criticality safety barriers that had been designed into the IDR process were: 1) control of the process to assure that dry powder was produced through a series of engineered controls and associated interlocks and alarms which are s
5 listed in the license application, and 2) verification that moisture is below specified limits before transfer of the powder from the favorable geometry check hoppers to the non-favorable geometry blender.
Licensee representatives stated that they recalled that these analyzers had not been reliable at the beginning of operation of the IDR system in the latter part of 1984 and early part of 1985.
At that time, both the moisture analyzers and the sampling and laboratory analysis were in place because the licensee had decided i
that the analyzers alone were not adequate.
When the I
check hopper moisture analyzers proved to be unreliable, the licensee removed them considering the sampling and laboratory analysis as sufficient to meet, j
the intent of the license requirement for moisture analysis of the material being introduced into the i
blender.
The licensee was not certain exactly when the moisture analyzers had been removed from the check hoppers.
The sampling and laboratory analysis method uses an automatic composite sampling device between the discharge and check hoppers.
Both hoppers have identical environments in that they share the same nitrogen purge which begins at the check hopper.
Licensee representatives stated that they believed that the sampling and analysis method for moisture determination was superior to the moisture analyzers, even if the moisture analyzers had worked properly, and that there was no safety significance related to the moisture analyzers having been removed.
The inspector and ONMSS agreed that the sampling in lieu of the presence of moisture analyzers in the check hoppers did not reduce the safety margin.
Licensee representatives, however, were unable to retrieve any documentation related to the decision to remove the moisture analyzers.
Subsequent to the inspection, the licensee reported the failure of the automatic sampling system due to plugging that had resulted following a modification to the sampling system which was performed on May 6, 1993.
This incident was. reported to the NRC operations Center on May 21, 1993 and was recorded as Event Number 25550.
The" licensee shutdown the IDR process and perforned an investigation'to determine the root cause of the system failure and to implement corrective actions.
Licensee representatives stated that they were purchasing one moisture analyzer to reinstall and will try to make it operational.
If successful, the licensee will purchase others and re-institute the use
i 6
of these devices.
Concurrently, licensee representatives have met with ONMSS to discuss a license amendment which would allow them to.make changes, of which this moisture analyzer verses sampling and laboratory analysis is an example, provided such changes meet the intent of the license application and do not decrease safety.
They planned to submit this amendment request in the near future.
The removal of the moisture analyzers was identified as an apparent violation of Section 2.2.14.1(14) of the license application (VIO 70-1151/93-03-03).
e.
Nuclear Criticality Safety Incidents Section 2.3.1.10 of the license application states that when non-favorable geometry is used, Westinghouse shall establish appropriate administrative controls, take into consideration identified contributing causes of-criticality accidents, demonstrate that such causes will be subject to administrative controls, and i
demonstrate compliance with the Double Contingency Principle.
Chapter 2, Section 2.3.1.5 of the license application states that all transfers of enriched uranium oxides from geometry controlled equipment or containers to moderation controlled equipment or containers shall i
require moisture analyses prior to the transfers.
I Licensee representatives informed the inspector of the following three NCS incidents which they had identified, all of which involved the material flow and control aspects of moisture control:
j 10/23/92:
E n r i c h e d Ur 0 from geometry controlled 38 polypaks was introduced into an non-favorable geometry blender without the required inoisture analyses being j
performed prior to the transfer.
3/9/93:
An inhomogeneous composite sample of U O 3 at which included material from a polypak which should not have been sampled, was submitted to the laboratory for analysis and resulted in'an analytical result.which was j
high in moisture and not representative of the batch of interest.
4/8/93:
Enriched UO from geometry controlled polypaks 2
was administratively released for introduction into a non-favorable geometry blender without performing the required moisture analyses prior to the transfer.
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The inspector reviewed the Nuclear Safety Analysis file with a licensee representative.
l (1)
Westinchouse Analysis of Safety Barriers The licensee chartered their Criticality Safety Assessment Team (CSAT) after the_May, 1991 GE NCS incident to perform and document Double contingency Analyses for all fuel handling and processing operations in the facility.
The CSAT had not analyzed the operations involved in=the:
above three incidents; accordingly, the Regulatory Affairs department analyzed the operation to determine NCS barriers for the purpose of l
evaluating safety significance'and reportability to NRC when the 10/23/92 incident' occurred.
The barriers which the licensee identified apply to all thrp:e of the above incidents and are as follows l'
l Barrier a:
According to-the licensee, the ADU calcining process and the UO to U 0 oxidation 2
3s process, with the high temperatures at which they operate and the controls on temperature, l
inherently produce dry material.
Under normal L
operating conditions, the process produces l
material containing less than 0.3 w/o moisture.
Barrier b:
The material is sampled, analyzed in a laboratory, and the'results are verified to be below the NCS limit of 0.3 w/o moisture prior to releasing the material for transfer to the non-favorable geometry. blenders.
l Barrier c:
According to.the licensee, operatorsL i
would recognize material containing greater than or equal to 7'w/o moisture and not introduce.it into the non-favorable geometry _ blender.
(2)
Westinchouse Criticality Safety Basis The calculational models which_were analyzed I
consisted of two configurations, homogeneous and-worst case configuration inhomogeneous.
The homogeneous model consisted of a 5000 Kg unreflected sphere of UO, and gssumed a density g
of : grams / cubic centimeter (cm ) (actual powder 1
'In the Westinghousa Fault Tree, the three barriers are interconnected through an "and" gate.
l l
8 3
density is 2.2 grams /cm ).
The modeled system with 7 w/o moisture yielded a K of.O.95 and is g,
the basis for the 7 w/o homogeneous moisture NCS limit.
The inhomogeneous model consisted of a 24. liter sphere of UOg (having an assumed powder density of-2.2 grams /cm ), containing 19 liters of water, and reflected by 36 inches of.UO with 0.3 w/o 2
moisture yielded a K of 1.0.
Using this result, g,
15 liters or equivalently 15 Kgs of water in the 5000 Kg bulk blender was used as the basis for establishing the 0.3 w/o moisture NCS limit.
Beyond the above described basis for NCS limits, the Nuclear Safety Analysis. file did not appear to contain any. documented analysis of fuel handling and processing accident scenarios from which to determine appropriate administrative. controls and demonstrate compliance with the Double Contingency Principle.
The failure to take into consideration fuel handling and processing accident scenarios and thus all contributing causes of criticality.
accidents was identified-as an apparent violation of Section 2.3.1.10 of the license application.
As a result, adequate barriers to implement the Double Contingency F.inciple were not established and when the incident of October 23, 1992 and-April 8, 1993 occurred adequate barriers were not in effect.
The remaining " barriers," which were not adequate to meet the Double Contingency, were the recognition by an individual that the material to be placed in the blender was of the wrong consistency and/or moisture content and the fact that the process inherently produced' powder'of low moisture content.
(VIO 70-1151/93-03-04).
(3)
Incident of October 23, 1992 Material whose moisture content had not been verified to meet the 0.3 w/o moisture limit was transferred and introduced into the non-favorable geometry 5000 Kg blender.
The licensee's evaluation of this-incident determined-that Barrier b had failed and that Barriers a and c'had not.
It is the NRC position that Barrier a is.not adequate and cannot be used for the purpose of satisfying the Double Contingency Principle because credit cannot be taken for controlling the process unless the following conditions are met:
9 1
- 1) licensee management and the operations and I
safety functions acknowledge that the process is being operated as a nuclear criticality safety barrier, 2) the process parameters are suitable.
for accurate control, 3) ~ operators are trained to 1
know when parameters are outside of safety limits and know the necessary action to assure safety, and 4) the control of the process as a nuclear criticality safety barrier is documented.in the licensee's safety analysis and in operating.
procedures.
These conditions were not all met.
Barrier b had failed.
The NRC determined that Barrier c was not adequate because the licensee's i
training and procedures did not address the operators' responsibility to visually recognize wet material nor were actions to be taken specified.
Accordingly, adequate Barriers were not in place following the failure of Barrier b.
The failure to evaluate the UO2 Powder prior to i
transferring it to the 5000 Kg blender was identified as a violation of Section 2.3.1.5 of the license application which states that all transfers of. enriched uranium' oxides from geometry.
controlled equipment or containers to moderation controlled equipment or containers shall require moisture analyses prior to the transfers.
This.
violation is being cited in conjunction with the violation specified in 2.e.2 above (VIO 70-1151/93-03-04).
i (4)
Incident of March 9, 1993 l
A polypak containing maintenance " scrap" was inadvertently included with a batch of polypaks at the end of an ADU run, and a sample from the polypak was-included in a composite sample for the batch.
The operator, however,. neglected to tumble the composite sample which resulted in-the' composite sample being inhomogeneous.. When laboratory personnel sub-sampled the inhomogeneous-composite sample, a portion was' selected which contained an excessive quantity of material from the " scrap" polypak.
Tho~resulting analytical result was 1.4 w/o moisture which was_not representative of the-average moisture content of the composite sample.- The high moisture analysis resulted in the material not being approved for blending.
Not tumbling the composite sample,.
however, could also have resulted in an analysis result which was less than 0.3 w/o moisture-if excessive non-scrap material had been contained in
. ~.
10 the sub-sample because the inclusion of the
" scrap" polypak did not appear to put the average weight percent moisture of the batch above-0.3.
The licensee's evaluation of this incident determined that Barrier b had failed and that Barriers a and c had not.
The licensee postulated that the source of the moisture in the " scrap" polypak had been from a water cooling jacket within a fitz mill at the discharge end of the ADU calciner.
In particular, the moisture could have resulted from condensation of moisture on the cooling jacket from the room air when the system had been opened, or through cooling jacket leakage.
It appeared that accident scenarios. involving these water sources had not been considered during the. safety analysis, and this type of moisture introduction emphasizes the inadequacy of Barrier a.
As stated in (3) above, Barriers a and c were not adequate.
Accordingly, adequate Barriers were not in place following the failure of Barrier b.-
The failure of Barrier b was identified as a violation of Sections 3.1.2.2 and 3.1.4.1 of the license j
application that requires operations to-be carried out in accordance with internal operating procedures (VIO 70-1151/93-03-05).
(5)
Incident of April 8, 1993 to Ugo oxidation operation j
Two polypaks from a UO2 s
whose moisture content had not been verified to j
meet the 0.3 w/o moisture limit were released j
administratively to be introduced into a non-favorable geometry 5000 Kg blender.
The material had not been put through the oxidation furnace, therefore was still UO and not Ujo, and 2
s an operator. visually recognized that the material l
and did not introduce these two i
was not U50s polypaks of material into the blender.
The UO.
I 2
was from a dry pellet grinding process.
The licensee's evaluation of this incident determined i
that' Barrier b had failed'and that Barriers a and i
c had not.
As stated in (3) above, Barriers a and c were not adequate.
Accordingly, adequate barriers were not in place following the failure'of Barrier b.
The failure of Barrier b was identified as another=
example of the apparent violation of Section 2.3.1.5 of the license application.
This 1
,w-
.g....
l e
11 violation is being cited in conjunction with the violation specified in 2.e.2 above (VIO 70-1151/93-03-04).
(6)
Identification and Reportina The 10/23/92 incident had been identified by an operations engineer, the 3/9/93 incident had been identified by analytical laboratory personnel, and the 4/8/93 incident had been identified by an operator.
All three incidents had been recognized and reported to licensee management in accordance with reporting practices which had been implemented immediately following the 5/91 GE incident and before the issuance of NRC Bulletin 91-01. These reporting practices were subsequently incorporated into Regulatory Affairs Procedure RA-107, " Internal Reporting, and NRC Notification of Unusual occurrences", which established reporting criteria in accordance with NRC Bulletin 91-01.
Procedure RA-107, however, requires notification i
of the NRC of a loss of a barrier when no more than one control remains for each additional barrier described in the subject system's double contingency safety analysis.
The licensee's inadequate double contingency safety analysis led licensee representatives to conclude that reporting of the incidents to the NRC was not necessary.
The failure to report is not being cited as a violation of NRC requirement because the root cause, failure to adequately implement the double contingency principle, as.specified in paragraph 2.c.2 is being cited.
(7)
Follow-up Activities Immediately following the 10/92 incident, a Criticality Safety Engineer was tasked with performing an investigation of the incident.
Some changes to the material flow and control aspects of the operation had been 1.aplemented, however, this investigation had not been completed when the 3/93 incident occurred and he was then also tasked with' investigating this incident.
Then the 4/93 incident occurred and Regulatory Affairs and other affected management, recognizing that all three incidents involved the material flow and control aspects of moisture control, shut these operations down.
While these operations were shut down, Regulatory' Affairs and other affected management analyzed the material flow and control aspects of the overall operation and implemented' enhancements a
12 in the system which their analysis had revealed.
These changes had not yet been finalized during the time of this inspection.
Licensee management, however, judged that the changes which had been implemented were adequate to restart operations prior to this effort being totally completed in order to " functionally test" those aspects of the changes which had been completed.
In addition to this analysis of the overall material flow and control aspects of the system, licensee management stated their intent to perform a-thorough root cause analysis of each of'the three incidents to learn what, if any, further changes to the system-may be r, quired.
(8)
Safety Sianificance As discussed above, the 0.3 w/o limit was derived from the worst case inhomogeneous configuration.
The 0.3 w/o limit (which corresponds to 15 liters or equivalently to 15 Kg of water in the 5000 Kg blender) assumes a scenario in which.the limit is exceeded to 0.38 w/o (which corresponds to 19 liters or equivalently to 19 Kg of water in the 5000 Kg blender).
This 19 Kg of water would have to migrate into the worst case inhomogeneous configuration of the model.
Given the characteristics of UOz powder to rapidly" undergo oxidation (sometimes referred to as burnback) which has occurred at several licensed facilities, a driving force to concentrate moisture could have been present.
The 0.3 w/o moisture limit was conservative, but if exceeded and followed by burnback, a critical configuration could have been produced.
The inspector observed the appearance and consistency of sludge from a wet pellet grinding process which licensee representatives stated contained approximately 10 w/o moisture.- This material appeared similar to mud or clay as opposed to powder or particles.
A licensee nuclear criticality safety engineer' stated that this visual effect would be less-dramatic with materials of lesser. density such as UO.
With 2
that type of material some change in appearance and clumping of the powder would occur.
It.is not known whether an operator would notice 7 w/o moisture and bring it to the attention of supervision since no training or procedural requirements have been promulgated.
As stated above, 7 w/o moisture in the contento of the l
.. - ~ - - - -.
13 blender would result in the K,n exceeding 0.95.
Five violations were identified as specified above.
3.
Non-Favorable Geometry Container Usage Review (88015, 88020)
During an NRC Operational Safety Assessment (OSA) of the licensee's facility, which was conducted during August 17-28, 1992, problems were noted with respect to the justification and use of, and preparation of safety analyses for moveable, non-favorable geometry (MNFG) containers.
Following the OSA, the licensee formed a multi-disciplined team to review the MNFG container issue and formulate recommendations to resolve the problem.
As a result of the OSA and telephone conversations between the licensee and the NRC, the licensee began providing bi-weekly status reports on the progress they were making in identifying the non-favorable geometry containers that were present in the Chemical Area and eliminating those containers that were not needed.
Four bi-weekly status reports were issued concerning the licensee's actions regarding non-favorable geometry containers.
These reports were dated September 4, 1992, September 18, 1992, October 2, 1992, and October 16, 1992.
An NRC followup inspection was conducted during October 28 and 29, 1992, which revealed that the licensee had made sufficient progress in correcting the problem that further bi-weekly status reports were not necessary.
In addition to the above, the licensee re-organized the Regulatory Affairs department and placed the criticality 4
engineers in another section.
This was done to allow more emphasis by one supervisor on criticality safety and by another supervisor on emergency preparedness, industrial hygiene, and chemical safety.
During a follow-up inspection in February 1993 the problems i
with control and use of MNFG containers, noted during the l
OSA, were cited as a violation of the license conditions.
During that inspection, the licensee's corrective actions regarding the identification, elimination, and/or justification and use of MNFG containers were reviewed.
The inspector noted that the licensee had eliminated approximately sixty-five percent (65%) of those MNFG containers that-had been in use prior to August 1992.
Of the MNFG containers remaining in use, the licensee had I
completed the required Nuclear Safety Analyses (NSAs) and was in the process of revising all the affected procedures to include specific controls that had been established for
)
their use.
It was also noted that the licensee had.
generated a new Regulatory Affairs procedure, RA-306,
" Movable.Non-Favorable Geometry (NFG) Containers in the Chemical Area," Revision (Rev.)
0, dated January 21, 1993, i
- = _ _ -
14 to define what a MNFG container was and specify the general requirements and controls for using such items.
A list was also included in the procedure which identified the number and a description of MNFG containers authorized to be located and used in each area of the facility.
During the current inspection the inspector reviewed selected NSAs.that had been completed for the MNFG containers that the licensee had decided were necessary for' continued operations.
The inspector also reviewed the associated procedures which stipulated.the specific' controls for using each MNFG container.
The NSAs and the procedures appeared to be adequate.
The inspector observed use and control of the authorized MNFG containers,in each area of the facility.
Only those MNFG containers that were listed as being authorized by procedure RA-306 were observed.
The inspector also noted that the MNFG containers were being controlled as specified in the general RA-306 procedure and in the various area-specific procedures.
No problems with respect to MNFG containers were noted.
No violations or deviations were identified.
4.
Followup on Previous Inspection Findings (88005, 88010, 88015) a.
(Closed) IFI 91-02 Followup on CNFD decision regarding modification of input configuration The licensee had evaluated this item and decided to modify the piping input configuration between the uranyl nitrate (UN) concentrator loop and the four-in-parallel holding columns so that the four columns would be fed simultaneously from the concentrator.
The inspector's review of related documentation and discussions with licensee representatives revealed that these piping configuration changes, at the time of this inspection, had been completad but had not.yet-been reviewed and released for use.
Reviewed documentation related to this item was contained in " Commitment Tracking System Report - Commitment ID:
NRC9102-CC.100"; letter no. RE-NAK-91-062, dated 11/11/91; letter no. NCS-NAK-92-116, dated 11/13/92; and the corresponding engineering change file.
Final review and release actions will be followed up on during a subsequent routine inspection, but the inspector was satisfied with the licensee approach.
This item is closed for record purposes.
l 15 b.
(Closed) IFI 91-02 Followup on particulars of technician verification of stirrer operation The licensee had evaluated this item related to the periodic verification of stirrer operation in the 7500 gallon UN product tanks.
Their evaluation verified that an operator checks the status of stirrer operation every four hours by checking the indication on a status panel at the tank farm. This on/off indication does not show that the stirrer blade is actually spinning, but I
rather that the stirrer is commanded to the position indicated.
Their evaluation concluded that this situation was adequate in that this stirrer is considered a secondary nuclear criticality safety control; i.e. the concentration of UN solution introduced into the 7500 gallon tanks is verified by two independent concentration measuring Barriers prior to introduction to the tanks.
The inspector discussed this item with a licensee representative and reviewed the corresponding following documentation:
" Commitment Tracking System Report - Commitment ID:
NRC9102-CH.100"; and letter no. RE-NAK-91-070, dated 12/4/91.
This item is closed, c.
(Closed) IFI 92-02 Followup on the adequacy of the licensee's procedures During an NRC inspection in March 1992, the licensee's procedures were reviewed.
The inspector noted that the procedures appeared to be very general and that the terminology used often varied within the same procedure.
During discussions with the licensee, they stated that their procedures were not very specific because their employees are trained in what they are to do and that detailed procedures were, therefore, not necessary.
Because this was viewed as a possible problem, the licensee formed a team in April 1992 to address the training aspects of this concern.
The team was given the charter to address various subjects including:
trainers' responsibilities, trainers' qualifications, selection of trainers, training program - customers,-
training program - content, revising and: auditing training manuals, and resources needed for training.
Because the issue of the adequacy of procedures was I
again brought out as a possible problem during the OSA l
in August of'1992, the licensee initiated another l
program to improve the procedures themselves.
A procedure system improvement plan was developed as part of the licensee's overall Safety Margin Improvement l
l 16 Program (SMIP).
The licensee plans to utilize the WesTIP methodology to analyze the existing procedure system and to design, develop, and implement an improved process including:
develop a structured procedure system, ensure that all procedures contain the necessary information, improve the procedure control system to ensure that procedures are understood and consistently followed, develop a cross-reference documentation index for procedures, and develop an audit process to evaluate overall system effectiveness.
Although this process is ongoing, this item will be closed and followed through followup of corrective actions outlined in the licensee's response to weaknesses identified during the OSA.
d.
(Closed) IFI 92-02 Followup on safety reviews of work orders performed by the licensee In response to a question about the adequacy of safety reviews of work orders, the licensee developed a series of safaty " procedures" or guidelines to be used/ issued along with the operations procedure during a specific work evolution.
The safety procedure lists various precautionary steps or actions that are required to be taken prior to or during the job.
The procedure also outlines the hazards that could be encountered while performing the work such as electrical shock, the presence of an acid, or the possibility of high temperatures or steam.
The inspector reviewed the j
safety procedures which appeared to be adequate when i
included and used with the operating procedure.
This item is closed.
e.
(Closed) IFI 92-09 Followup on the documentation of general and specific controls to be used for MNFG containers l
Following the OSA in August 1992, an inspection was performed to review the actions taken by the licensee concerning controlling MNFG containers.
During that inspection it was noted that progress had been made in eliminating and/or controlling the use of MNFG containers.
It was also noted, however, that the area-specific procedures in place to control MNFG container usage had not been updated and no general guidance was available concerning MNFG containers.
The inspector also determined that the Nuclear Safety Analyses (NSAs) for all the MNFG containers in use had not been completed.
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17 Since that time, the licensee has developed a general procedure regarding MNFG containers and revised i
specific procedures for controlling MNFG containers in the various areas of the' facility.
The licensee has also performed the required NSAs for the MNFG containers in use and has implemented the program to control the use of such items.
(See Paragraph 3 for further details concerning the MNFG container ~ control program.)
The general and specific controls l
implemented by procedures to control the use of MNFG containers appeared to be adequate.
The related NSAs also appeared to be adequate.
This item is closed.
f.
(Closed) IFI 92-09 Followup on completion of the NSAs for high and low priority MNFG containers See the discussion in the paragraph 4.e, above.
The licensee has completed the required analyses and they appeared to be adequate.
This item is closed.
g.
(Closed) IFI 92-09 Followup on complete implementation of the licensee's MNFG container control program See the discussion in Paragraph 4.e above.
The licensee has completed the implementation of the MNFG container control program and no problems or discrepancies were noted during this inspection.
This item is closed.
h.
(Closed) URI 92-09 Followup on inconsistent application of the licensee's area. postings, use of MNFG containers for collecting trash, and storage of favorable geometry containers.
The problems that were noted during the NRC inspection j
in October 1992, and which opened this item, were reviewed during this inspection.
With'the exception of the storage of empty favorable geometry containers, the-specific problems outlined have been. corrected and the corrective actions taken appeared to be adequate.
The licensee has formed a team to address the storage problem and an IFI has been established by the NRC to j
followup on this issue.
Therefore, this URI will be i
closed and the licensee's actions regarding the storage issue will be followed by the NRC as an Inspector Followup Item (see Paragraph 2.c above).
i.
(CAosed) URI 92-09 Followup on the investigation,
)
root cause identification, and implementation of corrective actions following the October 27, 1992, e
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18 incident involving enriched pellets being placed in a natural uranium cart.
Condition 9 of Special Nuclear Material License Number 1107 (SNM-1107) requires that licensed material be used in accordance with statements, representations, and conditions contained in Chapters 2, 3,
and 4 of the application dated March 26, 1984, and supplements thereto.
Chapter 2, Section 2.6 of License SNM-1107 states that special nuclear material processing shall be. conducted in accordance with approved written procedures or instructions.
Regulatory Affairs Procedure, RA-302, " Criticality Signs," Rev.
5, dated April 21, 1989, requires in part that area supervision is responsible to ensure compliance with criticality control parameters and instructions on criticality signs.
The Criticality Signs posted on the natural pellet carts state that pellet storage is authorized for enrichments less than 0.80%.
Regulatory Affairs Procedure, RA-207, " Radiation Work Permits," Rev.
7, dated September 2, 1992, states that a radiation work permit (RWP) is required for all jobs where radiation protection requirements are not covered by operating procedures when the concentration of radioactive contaminants is likely to be elevated by 10% of the Maximum Permissible Concentration [MPC)
(locally).
Quality Control Instruction, QCI-910101, " Pellet Inspection - Procedural Outline," Rev. 94, dated July 6, 1992, requires is Step I.A.3 that QC inspectors attach a Reject / Rework ticket (QC-203) to reject trays.
Step I.A.3 also stipulates that QC inspectors place rejected trays either on the feed conveyor or in the Engineering Hold Cart.
Step I.A.4 requires that questionable or reject trays that require P.A.-
Engineering disposition will be removed to the engineering disposition area.
The inspector reviewed the incident, the licensee's investigation of the event, and the corrective actions taken as a result.
On the morning of October 27, 1992, the licensee discovered that 82.4 kilograms (kgs) of 4.0 weight percent (wt %) enriched UOg pellets had inadvertently
._.c.
19 been loaded into and stored in a pellet cart specifically designated for natural uranium pellets only.
Upon discovery of this situation, the Area Manager immediately directed that the pellets be removed from the cart and transferred to favorable geometry polypaks.
Because one of the barriers to prevent criticality was lost, i.e. the administrative control that prohibited loading enriched pellets in the cart and exceeding the minimum critical reflected mass of 60 kgs, the licensee notified the NRC on October 28.
The licensee's preliminary investigation of the incident disclosed the following:
1)
The pelleting equipment involved, Manufacturing Automation Project (MAP) Line #2, had been used for grinding natural pellets between October 16 and October 20.
This was part of an operation to test the Pellet Visual Inspection System (PVIS).
Following completion of the natural grinding i
campaign, a 4.0 wt % grinding campaign began October 21 following an enrichment clean-out (ECO).
2)
ECO documentation indicated that all natural pellet carts had been removed from the area.
3)
When the situation was reported during a production meeting on October 27, the Area Manager and a nuclear criticality safety engineer immediately recognized the problem as a criticality safety violation and ordered the pellets removed from the natural uranium cart.
4)
The Quality Control (QC) inspectors who had been handling the enriched pellets stated that they understood that enriched pellets were not to be placed in the natural pellet cart, and recognized their error when they were made aware of the problem.
As immediate follow-up actions to the incident, the licensee held work-place meetings with QC inspectors, Pellet Area' operators,'and associated engineers and supervisors for all three shifts.
They were re-instructed in the proper control and utilization of natural pellet carts.
The Item Control System (ICS) was modified as well.
When QC inspectors perform transactions, using the ICS, placing acceptable product pellet trays into pellet carts, ICS compares the enrichment of the tray against the type of cart used.
The system now flags the inspector if enriched pellets
20 are about to be placed into a natural cart.
(This is the control that was in place at the time of the inspection.)
Permanent, clearly designated Engineer Hold Carts were placed on each line as well.
Another immediate action was to establish a formal investigation team to review the incident, identify causes, and establish long-term corrective actions.
Through the licensee's formal investigation, the following problems were noted:
1)
The testing of the Pellet Visual Inspection System (PVIS) resulted in trays of questionable pellets being " saved" that otherwise would not have been.
Also, the practice of keeping a dedicated Engineering Hold Cart on each line for the purpose of storing trays of questionable pellets was terminated two or three years ago.
The QCI had not been revised to reflect the current practice.
(The licensee indicated that this revision was not necessary because the operator and inspectors were trained to get an empty pellet cart and use it as the hold cart.)
2)
An RWP had been prepared to cover the grinding work.
The RWP had been approved by Regulatory.
Engineering for the time period from June 29 through July 31, 1992.
No extension authorized in writing had been given.
What was perceived to be verbal' approval was obtained.
3)
There were no ICS controls that would warn an operator / inspector who was about to place a tray of enriched pellets in a natural cart.
It is currently acceptable to store natural pellets in enriched pellet carts.
4)
The natural cart had not been removed from the q
area during the ECO as required.
This may have occurred because the door.probably remained open most of the time it was in the area hiding the criticality sign and other markings from view.
5)
The QC inspectors did not follow-the instructions in QCI-910101.
No reject / rework tickets were attached to the trays of pellets placed-in-the cart, the wrong cart was used, and the questionable or reject trays were not removed to the engineering disposition area.
The "save-process" for the reject pellets that was being used during this test period was not the usual process.
I
21 As a long term corrective measure, the licensee plans to modified all the carts to effectively make them all the "same" and eliminate the possibility of repeating this particular incident.
This will be accomplished by eliminating all the natural carts and replacing them with favorable geometry pellet carts.
The licensee was informed that failure of the QC inspectors to follow procedures was an apparent violation of License Condition 9.
However, since the licensee's efforts in identifying and correcting the violation met the criteria specified in Section VII.B of the Enforcement Policy, this violation will not be subject to enforcement action.(NCV 70-1151/93-03-06).
One non-cited violation was identified.
5.
Followup on Informatlon Notices (92717)
The inspector determined that the following NRC Information Notices (ins) had been received by the licensee, reviewed for applicability by management, distributed for review, and followup actions assigned:
Problems With Criticality Alarm Components /
systems, dated December 26, 1991.
Soil and Water Contamination At Fuel Cycle Facilities, dated February 5, 1992.
Uranium Oxide Fires at Fuel Cycle Facilities, dated February 21, 1992.
In reviewing the " data packs" that had been established in response to each of the notices, the inspector noted that the initial reviews had been completed.
Management had then assigned actions to be completed to various individuals.
Through a review of the documentation included in each of data packs; however, the inspector determined that many self-assigned action items had not been completed.
The apparent problem with followup of corrective actions and assigned actions was discussed with the licensee.
The licensee indicated that~no procedure had been written to delineate when a data pack is required or how one is to be prepared.
However, when an event occurs, when a violation is cited, or when an Information Notice is received,.these are reviewed to determine whether or not a data pack should be prepared.
In'the case of an event, if the problem is of a serious nature, a team is formed to investigate it and Operations would have the lead.
The team would then generate a report which would generally recommend corrective a
,.o 22 actions.
Following a review by Regulatory Affairs, the report would be forwarded to management.
Management, in turn, then would accept (or reject) the recommended corrective actions and make assignments.
Due to problems noted in the past with followup of corrective and/or assigned actions, the licensee' indicated that action items will, in the future, be assigned to Quality Action Groups (QAGs).
These QAGs will be composed of operations management and engineering support personnel from the affected area of the facility.
Regulatory' compliance engineers will also be involved in the QAGs.
When regulatory violations or NRC Information Notices are received, these are reviewed by Regulatory Affairs and actions are recommended.
If the situation warrants, the QAGs will also be involved in these action items.
A Regulatory Affairs technician has been assigned to check on i
the status of followup items and report on the progress made.
The licensee indicated that the report will be reviewed by the managers of Regulatory Affairs, Manufacturing, and Technical Services to ensure that items are completed and closed out in a timely manner.
6.
Exit The scope and results of this followup inspection were summarized on April 23 and May 7, 1993, with those persons indicated in Paragraph 1 above.
The inspector described the issuca reviewed and discussed in detail the inspection rest s and observations.
No dissenting comments were rece ed from the licensee.
Although proprietary material was teviewed and discussed during this inspection,-
proprietary information is not contained in this report.
Item _ Number Description and Reference 70-1151/93-03-01 VIO - Failure to follow procedures for working in a ventilation hood, for handling combustible scrap, and for posting a storage rack (Paragraphs 2.a, 2.b, and 2.c).
70-1151/93-03-02 IFI
' Followup on the licensee's efforts to resolve problems with floor storage and storage of empty favorable geometry containers (Paragraph 2.c).
70-1151/93-03-03 VIO - Removal of moisture analyzers required by license application (Paragraph 2.d).
4
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V
,.o 23 70-1151/93-03-04 VIO - Failure to implementLnuclear criticality safety-controls which were sufficient toscomply with the~.
Double' Contingency Principle whichi resulted in two examples of losing adequate barriers as a' result'of failure to comply withithe-license.
application and with procedural; requirements regarding performing moisture analyses prior-to transferring powder.fromifavorable to non-favorable geometry containers'(Paragraphs-2.2.2,~2.c.3L and 2.e.5),
70-1151/93-03-05 VIO - Failure to. follow procedure forfblending;a sample prior'to moisture; analysis (Paragraph 2.e.4).
70-1151/93-03-06 NCV Failure'of.QC inspectors to follow procedure for storage of' pellets, using an RWP, and';
dispositioningcreject pellets-(Paragraph 4.1).
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